Dr. Jonah Kule Memorial Lecture --10th anniversary of his death from Ebola

Below is a transcript of the Dr. Jonah Kule Memorial Lecture, delivered by Scott to the Federation of Uganda Medical Students Association on 31 March 2018 at 10:30am at the Makerere University Main Campus.

(it was a 45 minute lecture so be warned, it's a long read...)

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Good morning.  Thank you very much for the invitation to deliver the Dr. Jonah Kule Memorial Lecture to the Federation of Ugandan Medical Students Association. 

I would like to acknowledge the presence of Masika Constance, the firstborn daughter of Jonah Kule. She is a graduate of the Uganda Christian University, and was 15 years old when her father died from Ebola.  Her younger sister, Birra Phiona, who is studying Law at Uganda Christian University is also here.

It is fitting that I am delivering a lecture memorializing the life of Dr. Jonah Kule on the weekend of the Celebration of Easter.  Easter is the climax of the Christian calendar in which we remember the resurrection of Jesus Christ.  Easter weekend begins with the observance of Passover.  Christians call this Maundy Thursday.  Jews hold a traditional meal called the Seder during which there is a reading of the Haggadah, a Jewish text which means “the telling”. During the Passover Meal, the story of the Passover is recounted. It is a story of God’s deliverance of the Jewish people from slavery at the hands of the Egyptians.  I am here for a re-telling of the story of our friend, our colleague, Dr. Jonah Kule.  I have two objectives for this re-tellling.  The first is to honor the memory of our friend and colleague who gave his life serving the sick.  The second is to challenge you, a group of future doctors, to consider how you will live and work – and whether the life of Dr. Jonah Kule is one to which you might aspire.

 

Our part in the story began with our arrival in Bundibugyo District in 1993. We came as part of a Team, trying to bring life and redemption to a remote and forgotten district with efforts in health, education, church planting and Bible translation.  When we arrived, there were 49 Districts in Uganda.  In the education sector, the New Vision always published a list of the District Performance for senior secondary O-level results --which is a proxy I think of development – and Bundibugyo was always dead last.  My wife and I are physicians so our piece was in promoting health and healing the sick—preventive and curative health.  As we moved into needy communities with immunization campaigns and health messages we met a young energetic Clinical Officer named Jonah Kule.  Jonah was a Mukonjo, a person of the mountains.  We learned very quickly that this young man had a gift for shepherding communities. He could teach, persuade, correct, encourage, guide—and all the while lead community groups on a path of self-discovery and mobilization towards healthier lives--idn a way that we as outsiders could not…

 

We got to know Jonah and his family very well. He eventually had five daughters—Masika, Biira, Maga, Keren, and Serah—who were in the same age range as our own four children. We shared holiday meals together in each other’s homes. We traveled together. We were professional colleagues working for health in Bundibugyo. After a few years, Jonah shared his dream of going to medical school with us.  We decided this was a worthy investment of time and money, so we gave him the green light to pursue a medical admission. Jonah was over 30 years old so he took the Makerere University “Mature Age Entry” exam.  He scored in near the top of all who took the exam. He was called in and asked how he cheated.  He must have cheated—because it was not possible that a student from Bundibugyo District could have performed so well.  So, they deleted his result and sent him away.  He was determined, however, and came back the next year and again scored in the top three of all who sat.  This time they accepted his result and he was admitted to the Makerere University Medical School. 

Jonah was a smart guy, but biochemistry almost did him in.  I think he passed by 1%.   But he was very experienced seeing patients as a hardworking clinical officer.  So, he did well at MUMed during the clinical rotations.  But he was always singled out in class by the professors.  No matter which subject whether it was surgery or obstetrics—they would look at Jonah and say, “and if you are practicing way out in the bush with few resources—like, in Bundibugyo, this is how you need to think about this.”  It was a slight humiliation.  Calling out Bundibugyo as the least developed and most backward place in Uganda.  

 

Nevertheless, Jonah persevered and graduated in 2005 from Makerere—and was the first to graduate as a native born from Bundibugyo in 29 years.  The last previous Bundibugyo-born graduate was William Sikyewunda who went on to be a member of Parliament and the District Health Officer. The New Vision’s headline on 31 March 2005 said “Bundibugyo’s Reason to Smile”. He went on to do his Internship Year in 2006 at Rubaga Hospital where he was much loved and appreciated for his serious work ethic.

Our mission, World Harvest Mission, sponsored Jonah with a Bond Agreement that he would return to serve in Bundibugyo District for at least 5 years.  For Jonah that was not a burden – he desired to return to Bundibugyo.  Immediately upon finishing his internship at the end of 2006, he did return to Bundibugyo.  He was immediately posted to the District Hospital.  It was a place he knew like the back of his hand since he had worked there for many years as a Clinical Officer prior to attending medical school. But there was still a requirement that he have an Official Tour at the time of his posting. On that tour, he was shown the Operating Theatre where he found a pregnant woman lying on the operating table. He asked why she was lying there and was told that she was waiting for the family to come up with the money for the surgeon before he was willing to do the surgery.  Jonah was annoyed and immediately terminated the tour.  He said, “Get me theatre scrubs and boots…I will operate on this mother—for no money.”  That story spread like wildfire in the ensuing days.  “Dr. Jonah is here… and he is not charging money to do surgery!!”

 

Jonah came back not just to be a doctor but to stand up to the rampant corruption.  That action shook up the District.  But life became hard for him.  Not everyone was happy that he came back to serve.  There were those who feared him and were jealous.  Everybody knew that Dr. Sikyewunda came from Makerere Medical School and became a member of Parliament.  People began to talk already that Dr. Jonah would be the first Mukonjo Parliament Member from Bundibugyo.  That was a radical idea.  I don’t think Jonah was entirely opposed to the talk.  He knew that corruption was rampant and might need to be cleaned out from within.  But I think he thought that would be some years down the road. 

So, he began to serve his people…

So, when there were a rash of deaths in Kikyo Sub-County (a mountainous area on the slopes of the Rwenzoris) in August of 2007 (six months after he began his posting), he took an interest.  He went up and treated people and investigated.  There were a cluster of deaths in one family – about five.  The father and all of the sons of one family—and then soon many more from that clan.  So, the pattern seemed to be infectious.  In retrospect, it is thought that these men were involved in butchering monkeys hunted in the mountains and then many more died who were involved with the burials. But that was covered up because it was an illegal practice.  Jonah brought in the District Surveillance Officer who sent off samples for testing for Hemorrhagic Fevers to UVRI.  The tests were negative.  There were no hemorrhagic features clinically.   Malaria tests were also negative.  It was mostly a picture of fever, vomiting and diarrhea.  At the time -we thought it might be typhoid.

 

Jonah passed by our house one day on his way up to the Kikyo Health Center.  Jennifer went into our stores and gave Jonah all of the Ciprofloxacin, gloves and alcohol hand sanitizer that we had.  He was in a hurry, but we insisted that he wait until we get these supplies together.  He did wait but as he pulled out on his dilapidated motorcycle he laughed and said, “I must serve my people.  If I die, then I die.”

And so it went.  Things smoldered and flared through September, October and into November.  Finally, on Thursday 29 November 2007, we got a call informing us that the CDC figured out that this disease was due to a new strain, the fifth identified, of the Ebola virus.  Much later in 2008, it was given the name Ebola bundibugyo.  Nobody in Bundibugyo or Uganda was happy about the fact that it was named for a place in Uganda.

 

So, this was the 17^th documented outbreak of Ebola since 1976.  All of the significant clinical outbreaks had occurred in Africa except for some of laboratory contaminations in other parts of the world.  The last previous Ugandan outbreak prior to this was in Gulu in 2000.  Uganda lost another hero due to that outbreak, Dr. Matthew Lukwiya, who died while caring for Ebola patients at the St. Mary’s Hospital in Lacor on 5 December 2000 – almost exactly 7 years prior to Dr. Jonah’s death.

As soon as the diagnosis was announced, Uganda MOH epidemiologists visited Bundibugyo and reviewed the records of many of the cases as they could find and decided that officially speaking (during that early period of the epidemic) there were 79 cases with a 43% death rate.  My own opinion is that it is a significant underestimate.  They used extremely strict case definitions and had no medical records for many patient deaths which made it impossible for them to be categorized as Ebola-related deaths.

So, we received the news from the USA CDC and immediately changed our approach to the way we handled patients, but by that time it was too late….

So, let me try to walk through the timeline of the final ten days of Jonah…

Friday 23 November  is the day Jonah believed himself to have been infected. That was the day he and I examined Jeremiah Muhindo.  Ebola experts call this type of patient a “super-infector”.  Very sick patients with high viral loads and lots of caregiver exposures.  He was an important man in the community – many people were involved in his care.  There were five health care workers who died at Bundibugyo Hospital and they all had contact with this patient:

--Jonah

--Rose Bulinpikya, nurse matron

--Johnson Kiza nurse

--Joshua Kule,  senior clinical officer

-- Asanasio Matte, ophthalmic assistant. (few of the patients in this epidemic had bleeding manifestations, but many did have conjunctivitis, so the ophthalmic assistant got involved – again, before we knew it was Ebola).

In between two of the times we saw the patient together, Jonah went in alone and arranged a face mask of oxygen onto the dying man, hoping to provide some relief or comfort. He was not wearing gloves because he could not find any at the hospital at that moment, and he felt that his friend needed the oxygen. That was his greatest exposure.

Sunday 25 November Jonah traveled to Kampala to pick up Masika from school as they were breaking off later in the week.

Wednesday 28 November he began to notice a headache, and wondered if he was getting malaria. (5 days from last exposure, though of course he’d had earlier ones too).

Thursday 29 Nov the EBOLA epidemic was announced by the Ministry of Health. Jonah’s headache persisted in spite of first line malaria treatment, and he vomited twice. He instructed his family to wash the floor with bleach, to not touch him, and to not share his food or drink. He picked up his oldest daughter Masika from boarding school, and by the time they came home he was feeling weaker and worse, slumped over on his young brother’s shoulder. We talked to him on the phone about this time – our first time to talk since the announcement of the Ebola epidemic.  I asked “How are you doing?”  With a sort of nervous laugh, he said “well, I’m not feeling so well.”

Friday 30 Nov  he had two malaria smears at a private clinic up the road from his house, one positive and one negative. Though he still hoped his illness was malaria, he talked to a doctor friend who encouraged him to be admitted, so they hired boda-bodas and both rode to Mulago Hospital. There he was put in an isolation tent.

Saturday 1 Dec  a blood sample was taken to test for the Ebola virus.
Sat to Monday he was mostly up and talking during the days, still having fever, vomiting, and some diarrhea. Then his urine output slowed down, so the staff began to give IV fluids, but in retrospect he was not dehydrated but rather in renal failure. He was thirsty, and at times hungry. He remained optimistic until Monday that he would recover. His family would come and see him from outside the tent flap, talking loudly to communicate but not touching. The Mulago Hospital doctor assigned to his care had fled, but MSF Spain doctors checked him a couple of times a day. His young brother sometimes entered the tent to care for him when no nurse or other medical person was available. He was alone much of the time.

Monday 3 Dec he began to have chest pain. He told his family this was a bad sign, that he had seen patients and when they had chest pain they were getting much worse. His brother describes finding him reading a medical text and thinking through his symptoms and what was happening. He read them some Bible verses.

Tuesday 4 Dec his chest pain became worse. He could not always talk because of breathlessness, taking several breaths to get words out, so his brother just kept quiet. He also felt a lot of abdominal pain and weakness. His young brother was finishing A levels and left to take his last exam. When he returned he found that the MSF team was in the tent and they told him to wait somewhere else. Later he saw Jonah’s body. I think the hardest thing for the family was that Jonah died without any of them around, alone in that tent. That’s hard for us too. His brother and the Mulago staff decided that it was best not to tell the family that day, they should keep it under wraps until the morning. But Jennifer did inform the family due to direct information from MSF, for which his wife and sister were very grateful.

The picture of Jonah in this situation is somber but not desperate. He knew what was happening to him. He followed his own symptoms and watched them unfold. He knew the choices he had made to care for patients might cost his life. It was five days from exposure to illness, and six days from the illness to death.

After Jonah’s death, we spoke with doctors from MSF who had cared for him.  It was spine-tingling to hear Jonah speak from beyond the veil.  Tuesday afternoon, he was still walking and talking and said to them, “I have seen these patients die and I know that I am dying.”  I don’t think his doctors really believed him.  Moments before he died he said, “I am going to die now. And I pray that no one should ever have to die of this disease again.”  Right to his last moment he was thinking like the compassionate doctor that he was, looking beyond himself to others.

The final numbers of the Bundibugyo Ebola epidemic are not huge:

Cases: 143

Deaths: 36

Case Fatality Rate (CFR): 25.2%

The CDC Team in Atlanta published a summary in the journal, Emerging Infectious Diseases, and they only officially recognized those Ebola patients who had laboratory confirmation of their infections:

Total infections: 56

Total deaths: 17

CFR: 40%

 

This is almost identical to the overall death rate of the massive Ebola epidemic in West Africa of 2015-16.

Ironically Jonah’s death was not included in the official tally of deaths of the Bundibugyo Ebola epidemic because he died in Kampala.

These numbers are super tiny compared to the 2015-16 recent epidemic in West Africa where

Cases: 28,616 (200x bigger)

Deaths: 11,310 (300x more)

CFR: 39.5%

Bundibugyo was not the largest epidemic in history.  But we did learn more about the disease as a result.

It was a tremendously organized effort.  Large organizations came and invested enormous amounts of manpower and money:  the Uganda MOH, Uganda Red Cross, Medicins sans Frontiers, the USA CDC, and the WHO.  There was one member of the WHO team who had been present at ALL of the previous Ebola epidemics.  He was primarily interested in trying to understand where the Ebola virus was coming from.

 

The Ebola Task Force included all of these organizations and was headed by the RDC and the Uganda MOH.

It was composed of a number of sub-committees:

1.    Clinical Care (MSF)– organizing the care of the sick

2.    Social Mobilization (MOH/Red Cross)—the community educators putting out messages of prevention

3.    Contact Tracing (WHO)– following up on those potentially exposed

4.    Lab (CDC)

5.    Logistics/Finance – Ug MOH

 

We learned this about Ebola:

Incubation: 2-21 days (the larger the viral exposure, the shorter the incubation)

Transmission: contact (no evidence of airborne transmission – except perhaps droplet transmission when health care providers have been sprayed down and blood has been aerosolized).  One brief anecdote here…The Sunday after Jonah died, Jennifer and I were home alone, having breakfast.  It was eerily quiet.  No kids (we sent them to Kampala so they wouldn't be at risk if we got sick).  No visitors because people thought we might be infected…and then I cell phone rang.  The guy on the other end of the line said, “Please hold for the President…”  President Museveni then came on the line.  We had a 10 minute conversation in which he asked lots of specific and intelligent questions about Ebola.  Specifically he wanted to know if Ebola could penetrate intact skin (my best answer: NO)  because he was trying to make public health recommendations for his country. At the end of the conversation he asked, “Is there anything I can do for you?"

I always regretted that I didn’t ask him for Ugandan citizenship for me and Jennifer :(

Reservoir: to the best of my knowledge it was during this epidemic that they made progress in understanding that the long-term reservoir of the Ebola virus was Fruit bats.

Intermediate host: primates (it is believed that the first cases in Kikyo on the mountainside occurred in a family who were hunting and butchering monkeys)

Those at risk: Health care workers and family care givers and especially those that bury the dead.

This is the insidious and seemingly evil part of this virus.

Let me just say a little bit about Jonahs burial…

We lived in Bundibugyo for 17 years and we attended dozens if not hundreds of burials.  Jonah’s was unlike any other we ever attended. 

Since Jonah died in Kampala, his body had to be transported back to Bundibuygo.  That was done by the Doctors Without Borders – Spain team.  The district leadership planned bury it with no ceremony, no attendants, not even his wife. We strongly objected. We knew there was no danger to standing a few feet away and watching the MSF team put the coffin into the ground. We drove Melen, the three oldest girls, his sister Sophia, and his mother, to Bundibugyo Hospital. When we arrived the other two staff were just being buried.  I called the DDHS thinking someone from the district should show the courtesy of attending the burial, and he and the LC5 came, as well as a handful of medical staff. We asked Melen what she wanted, she only wanted to be sure that someone prayed. We circulated looking for someone who was willing to sing, and thankfully found a Red Cross mobilizer who led hymns while the coffin was unloaded. Again people tried to keep Jonah’s family away, but there was no reason for that. Because Jonah’s body was decontaminated and enclosed in Kampala, the infection control protocol for his burial was less than for the two who died here. The team merely wore gloves, and MSF allowed the girls and relatives to stand by the side without touching anything. When the coffin had been lowered on ropes, Scott asked for a pause. He took out a Bible and read.  And they stood at a distance.  Quietly.  While the MSF Burial team lowered the coffin into the ground. 

 

By our estimates only his youngest brother and his mother had any potential exposure, touching him or cleaning up from his sickness. But the entire family was ostracized as dangerous and put into quarantine for 21 days.  It was harsh.

Jonah’s wife did receive a small worker’s compensation lump sum from the government since he died while doing government work, but inexplicably they published that fact and the sum in the New Vision.  This was a horrible decision as every distant relative descended on Melen, trying to vie for a piece of the pie.  And Melen was pregnant with their sixth child at the time of Jonah’s death.  A child he would never meet.  And it turned out to be their first boy, now named for his father.

 

At the graveside, as they lowered Jonah’s coffin into the ground I read

John 12:
But Jesus answered them, saying: The hour has come that the Son of Man should be glorified. Most assuredly, I say to you, unless a grain of wheat falls into the ground and dies, it remains alone; but if it dies, it produces much grain. He who loves his life will lose it, and he who hates his life in this world will keep it for eternal life. If anyone serves Me, let him follow Me; and where I am, there My servant will be also. If anyone serves Me, him My Father will honor.

 

Jonah fulfilled this description as well as anyone we have ever known, not loving his life too much, being willing to die for the good of others. 

I would like to pause here for a moment before I move to my final points—to address the issue of how we deal with such a tragedy.  How do we make sense of the death of a good man, one who we have poured so much into, who has just finished six years of medical training who has come back to serve his people, who is the father to five children.  It makes no sense, humanly speaking.  I will say two things:

First, We cannot see the ways of God.  God is all-knowing and all-loving and all-powerful. We know these things from the ways he has revealed Himself in history. But sometimes we cannot understand His ways.  We must accept that God is Mystery –with a capital “M”.  It will never make sense to us – but we cannot see all of history in the same way that God can.  Look at it this way. If you wanted to understand the ocean, but you only had a cup of water from the ocean.  You could say that it is salty, that it might have some sand, and some microorganisms in it. But that cup of ocean water could never reveal the depths of the ocean and the undersea world of creatures and vegetation and beauty.  In the same way, we only see dimly now through a veil.  God is beyond our understanding…

Second, there is some good that has risen from the death of Jonah…we established the Dr. Jonah Kule Memorial Leadership Scholarship Fund to sponsor students in medicine and other health-related education.  We have seen 6 doctors sponsored at Mbarara and KIU; in nursing at UCU; in lab medicine at Mulago and Mengo; in anesthesia at Mulago.

Those sponsored in medicine included Baluku Morris, Monday Julius, Katuramu Tadeo, Peter Kisembo, Isaiah Kule, Birungi Fred.  And they are all bonded to 5 years of service in Bundibugyo (though it seems unlikely at this time that the District will have the finances to hire them all).

So, what does this mean for us today?

How should we then live?

We are here today remembering and re-telling the story of the final days of Dr. Jonah Kule.  Is his life a model for us? 

As medical students, I used to presume that you were motivated by a sense of service and calling.  That there was some desire to heal the sick, to comfort the dying, to help your fellow humans.  These last few years though I’ve run into more and more young doctors who are motivated only by money.  I have a Kenyan colleague who seems to be willing to do a Cesarean delivery on every woman possible to make as much money as possible.  There is a doctor in Bundibugyo recently who has been doing unnecessary hysterectomies in order to make as much money as possible.

I would like to leave you today with one more verse from the Bible, Micah 6:8

He has told you, O man, what is good:

And what does the LORD require of you

But to do justice

And to love kindness,

And to walk humbly with your God.

 

I would implore you as medical students to reexamine the reasons why you entered medicine. Of course, medicine is a sure meal ticket and potentially a lucrative career.  I’ve heard so many intellectual justifications about why you DESERVE to be living comfortable and convenient lives.  You’ve worked hard.  You’ve suffered.  You’ve put yourself in harm’s way.  You deserve to drive a nice car, own a big house, wear the best clothes, and to send your kids to the best schools.

But let’s look at this verse from the Book of the prophet Micah…

WHAT DOES GOD REQUIRE OF YOU…

1      DO JUSTICE…God does not call us to lives of convenience but to lives of justice. 

The Bible is full of evidence of God’s concern for justice:

Isaiah 58

Cry loudly…raise your voice…declare to My people their transgression...on the day of your fast you find your desire, and drive hard all your workers…Is this not the fast which I choose? To loosen the bonds of wickedness, to undo the bands of the yoke, and to let the oppressed go free? Is it not to divide your bread with the hungry and bring the homeless poor into the house?

If you remove the yoke from your midst, the pointing of the finger and speaking wickedness, if you give yourself to the hungry and satisfy the desire of the afflicted then your light will rise in darkness…You will be like a spring of water whose waters do not fail.

And I would like to make a distinction here between charity and justice.  Charity is giving something to someone in need.  Caring for the poor.  This is a good thing.  But justice is doing something in which there is a structural change in the system that oppresses the poor and those in need.

You see corruption and deceit in your communities, in your hospital. People taking money from patients for dressing changes and placement of IVs.  For services that are declared free by the government. I daresay that if we see it and don’t speak up then we are complicit in promoting injustice.  Injustice is an oppression of the poor –who have no other resources to access private care. 

Jonah stood up to injustice when he rolled up his sleeves and did the CS for the woman on the table who had no money.  He stood up to the corruption, called it out, and did the just and right thing.  He challenged the system of corruption and publically condemned in it word and deed.

Doing justice is doing the right thing.

What is that for you today? 

What does that mean for you in your life? 

How can you be working for justice in an unjust world? 

Does that require some sacrifice in your life – of course, it does.

2.  LOVE KINDNESS…This is about who we are as people.  How we treat each other. 

Aristotle defines it as being "helpfulness towards someone in need, not in return for anything, nor for the advantage of the helper himself, but for that of the person helped.

Kindness is a comfort to those it touches.  It makes their life easier, more pleasant.

Another way we can think about Kindness is generosity.  Giving.  Some say it’s more blessed to give that receive.  To live generously is to live with a spirit of kindness.  Always looking for opportunities to bless other people.

Philippians 2:3  - count others more significant that yourself…

There are so many organizations and movements in our culture and in social media extolling the virtue of kindness…

The Kindness Boomerang, the LifeVestInside, Random Acts of Kindness, Pay it Forward…

The common thread here is doing something for someone else expecting nothing in return.

Usually these are small acts. 

Jonah was a kind man – one who thought always of others first.  Of how he could serve, of how he could help…

What opportunities for showing kindness do you have in your life?

 Are you touching others with unexpected, unmerited kindnesses? 

3.  Walk Humbly with your God.

What does that mean to walk Humbly with God?

To be humble in the Bible means literally to ‘submit yourself to the humbling process of God’

It means you submit control to God.  You have faith that He is in control.  That he is great and we are not.

I remember one time Jonah and I were traveling together.  It was early in our friendship.  He was still a Clinical Officer.  We were staying in a guest house together.  We had a small room with two beds.  I think we arrived late.  We ate dinner and I came back and collapsed into bed.  Jonah took a shower.  By the time he got back I was almost asleep.  He said, “Scott did you pray? We need to pray before we sleep.”  I smiled and nodded.  He prayed, giving thanks for the day, for our safe travel, for our accommodation and our meal.  And asked that God would protect us through the night and give us rest.”

Jonah was a man who pursued justice, who practiced kindness, and who walked humbly with his God. 

He gave his life serving others.

He is an example and a hero to his family, his friends, to Uganda, and to the world.

Masika, little Jonah, Mbusa, Melen, and Biira

All Things New: Celebrating Resurrection

A dear friend wrote a book about cross-cultural inner-city ministry to the urban poor, called A Thousand Resurrections.  I highly recommend the book, and I also love the title. Today we celebrate THE resurrection, but we also remind ourselves that that event set in motion a thousand, a billion more.  One of the last recorded words of Jesus was this phrase: Behold, I am making all things new.  

Today we worshiped with a multicultural crowd in a garden, a foreshadowing of Heaven.  And I thought about the fulcrum of history, and whether there was any evidence of all things becoming new around us, and I think there is.  Sure, we have a long way to go in seeing the Kingdom operating on earth the way it does in the dimension of God's dwelling.  We are people living in broken systems, sharp edges, and resurgent grief.  Still, consider this. In most of the world, slavery is illegal even if it is not completely exterminated.  Child deaths per year in the world have fallen by half in the time I've been a pediatrician, as infant and maternal survival become more the norm.  Girls can go to school and women can vote in the majority of societies.  A smaller percentage of the world is hungry.  Think of the explosions of art (including music!), creative inventions, scientific insight, even in our own lifetimes.  Think of the inexorable growth of the church on this continent and many others.

That inflection point 2000 years ago makes this a celebratory day.

So, celebrate Easter.  Here is one of the songs we played this morning, under the acacias as the tropical boubous sang in the scrub, which praises the transformation wrought upon the cross with my favorite line "and as you speak, a hundred billion failures disappear . . "

And here is a Malcom Guite sonnet for the day (from Sounding the Seasons), which captures this idea of cascading resurrections, night to day, healing and dawn and newness and hope:

XV Easter dawn

He blesses every love that weeps and grieves
And now he blesses hers who stood and wept 
And would not be consoled, or leave her love's 
Last touching place, but watched as low light crept
Up from the east.  A sound behind her stirs
A scatter of bright birdsong through the air.
She turns, but cannot focus through her tears, 
Or recognize the Gardener standing there.
She hardly hears his gentle question, 'Why,
Why are you weeping?', or sees the play of light
That brightens as she chokes out her reply,
'They took my love away, my day is night.'
And then she hears her name, she hears Love say
The Word that turns her night, and ours, to Day.

Honoring Dr. Jonah Kule: Easter Saturday and Aching Liminality

Ten years ago, our dear friend and colleague died in an Ebola epidemic that struck our area as we worked together.  We did not.  So today Scott was invited to address the Federation of Ugandan Medical Student Associations at their annual general assembly at Makerere University, to give a memorial lecture challenging students to follow Dr. Jonah’s footsteps of service and sacrifice.  

pre-lecture, with Biira (center) and Masika (right), Jonah's two oldest daughters

His two oldest daughters, who were 12 and 15 at the time of his death, attended with us, along with two of our “kids” John Balitebiya who grew up as our next-door neighbor, and Dr. Katuramu Tadeo whom we embraced when he was Luke’s classmate at Christ School.  We had an absolutely lovely dinner with the handful of our young people from Bundi who are still in Kampala area in school the night before, a real vision of the Kingdom of Jesus coming to earth as these former orphans grow into their roles as doctor, nurse, business administrator, accountant, banker, lawyer, development director.

Dinner celebrating some of our favorite 20-somethings

John and Dr. Katuramu joined Jonah's daughters and us for the lecture

The leadership of the medical student association intentionally wanted to bring a message of outreach and integrity to their fellow students.  And we were grateful for the opportunity to address about 150 student leaders from multiple schools across the country.

soon-to-be doctor student leader Meddy thanking Scott for coming with a certificate of appreciation

Scott taught a bit about the biology of Ebola and the reality of an epidemic response, detailing the way the epidemic unfolded, the investigation, the published results.

But the bulk of the talk was about remembering Dr. Jonah, about his character, about his story, about his faith.  Scott talked about how we as doctors handle such a tragedy, and how we interpret God's work through a lens of faith.  He ended with Micah 6:8:  do justice, love mercy, and walk humbly with your God, a life guide for all these future doctors.

Though we’re all smiling in this pre-lecture photo, the memories of the day were poignant, and some quiet tears were shed on our supportive front row.  Afterwards we sat with the four from Bundibugyo having tea and continuing to remember their father and mentor with more stories, stories they barely remembered as children but appreciate now as young adults.

And as we said goodbye, Scott read aloud today's devotion's last paragraph: “On the way from death to life, there is Saturday. Sabbath day. Rest. How do you rest when your world falls apart? You rest in the restlessness. I know that's demanding; more demanding than we'd like. But that's the nature of living along the aching liminality of Holy Saturday. Our transition from death to life, through the breath-taking disorientation of Holy Saturday, into the shocking gasp of hope on Resurrection Sunday.”

So appropriate that this lecture and this visit occurred today, on the achingly liminal Saturday that represents all of history between Jesus and Heaven.  Our worlds fell apart ten years ago, yet we live in the shocking hope that tomorrow’s resurrection will redeem us all.

Good Friday

This Tissot watercolor, Son of the Vineyard (featured a few days ago on the Biola site) questions the "good" in Good Friday.  The grey death tint of the body thrown outside the wall onto a heap of stones matches the somber sky.  The perpetrators hustle away, climbing like thieves back over the wall.  It is a snapshot of apparent defeat for all that is good.  

The naked vulnerability of the sprawled murdered form is, in that moment, accomplishing what millennia of religion and power and rules and laws and rituals could not.  A substitute broken by evil that not only pays behind all the wrong ever done, but pays it forward in actual transformation.  The Jesus-figure's body blends with the stones, hinting of the unseen reality: this rejected body will be the cornerstone of an all-things-new dimension. The drained blood will blossom in the sterile vineyard behind, bringing life and joy. And not just for a few deserving folk.  For all of us, all of us running away and climbing over walls.

But today, we consider the shocking hour when God entered into death itself.

And even before we see the grapes bursting with wine on the fruitful vines, even before we see life breaking out of the stones, we hold onto the Goodness of Good Friday by faith. The goodness of that love, that comes to us as the crushed body and bleeding side.

For in this hour when the dying night lingers

Unwilling to surrender its waking darkness
Over your face and fevered brow, my torn fingers
Will stray bringing such comfort
As may claim your doubting heart.
(Abioseh Nicol, African Easter: Good Friday)

Walking away from the meal: thoughts on Passover and Judas

Today we remember the Jewish passover, the ancient tradition instituted by God through Moses, in which the story of the descendants of Abraham as slaves in Egypt freed by miraculous intervention is told and retold.  And because we are learners who live in bodies, this story comes with props, bitter herbs and pierced flatbread and cups of wine.  This is the very meal Jesus was celebrating with his twelve disciples on the night he was betrayed.  And though the meal is meant to create community, a common story, a redemptive framework upon generations of suffering, an assurance of things hoped for . . . Judas walked out that night.  This was the painting featured in today's Biola Lent devotion:

The background is a scene of sustenance. Food, wine, readings, prayer, talking, laughing.  Friends.  Yet Judas is glancing back for one last glimpse of that light as he heads into the shadow.

Which is an important detail.  This moment sets in motion the entire arrest and crucifixion, yes.  But this moment also encapsulates God's choice to effect history through humans.  So often when we look at the mess we've made, we wonder why God doesn't immediately zap out all the tears and straighten everything up right now.  But Jesus let Judas walk away.  And ever since, redemption comes quietly, one man dying and rising, and two millennia of followers doing the same. Billions of daily choices, to embrace the light, to sit at the table, to raise a glass to Jesus.  Or to turn away from the feast, to slip into the dark shadows of hate and greed and jealousy and violence.  We will never fully understand the mystery of that plan, of how God's goodness and love win the universe over to wholeness in a sure and inevitable plan that still lurches along asking humans to participate. Once for all on Easter weekend, then seeping out to the frayed edges every second since.

The nation freed at Passover turned back from freedom repeatedly.  They remembered Egypt with rose-colored longing whenever the going got too tough (and it was tough).  And we daily devalue the bread and the wine set out for us as we cram all kinds of empty calories that cannot satisfy.  

The blog has been quiet as we traveled to the Christian Medical and Dental Association biannual meeting for continuing medical education for health care providers all over Africa, the Middle East, central Asia.  Over 900 doctors, nurses, therapists, parents, kids, professors, program directors, board members, etc assembled for nine days of an overwhelmingly rich meal.  Seven lectures a day x 4-8 choices per time slot x 9 days of programming, plus morning preaching and evening extras . . it was a feast, for sure.  We were challenged to some big-picture strategic thinking and updated on the science of medicine.  We had numerous meals with younger (mostly!) medical families, hoping to encourage them.  We cheered on the Sergers giving presentations . . . after almost two decades of coming to these meetings as the only doctors our Serge area, we had a solid team of co-workers at this one, and most of them in teaching roles! The conference is like the table in the background of the painting, rich with fellowship and content.  But now we and others have the choice to embrace and continue, or turn and walk away.  Praying that we will stay with the table even when it's hard to see Jesus there, and not be fooled by the shadows.

Another rich table, Rodger B instructing me on intubation skills at a workshop at the conference, photo by Ari

we had a full day off and hiked up a small mountain in a protected area along the coast, which for us is an invitation to God's feast of beauty in nature

In that same spirit, prayers appreciated for Scott as we head to Uganda tomorrow.  He's invited to speak at a weekend conference for Ugandan medical students, in memory of Dr. Jonah Kule.  We'd like to challenge them and point them by faith to sit at the table of service with Jesus, and not go chasing unsatisfying wealth and comfort.  

Blessings to your Easter weekends.  Here's the Passover Guide we like though I'm sure there are many, and again the Biola link for the Scripture-poetry-art-music-devotional thought-prayer each day.

A blanket, a mirror, and a gift

Scott preached at our church today, the wrap-up sermon of 1 Peter as we have been working our way through the book, a sermon that aptly addresses this season of approaching the cross.  So here is a brief summary of what he said from one listener, me.  1 Peter is a book written to believers who were suffering, countering the false idea that trials cease when faith enters.  Chapter 5, the final chapter, gives them three ways to persevere in the midst of suffering.  A blanket, a mirror, and a gift.

First, we are called to a path of humility, which is contrasted to a life of anxiety (5:6-7).  The cares of the world we often wrap around ourselves like a blanket.  Success, jobs, the future, financial security, popularity, admiration, look like they will comfort, but instead they distract and choke.  If we throw off that false security blanket, cast our cares on God, then we relinquish illusions of control and embrace a humble dependence on God's goodness.  In humility we surrender our will to seek the good of others and the glory of God, which paradoxically bolsters our perseverance.

Second, we are called to be alert (5:8).  Scott reminded us that we are in a battle, in a world broken by evil where that very breaking, where our own sin, where the deceiving prowling lion of personal spiritual forces, where the discipline of the Creator's merciful order, all mysteriously embattle us in troubles.  So we hold up the mirror of truth to examine our own hearts and to look behind us for the ill-intentioned devil ready to pounce.  Like real soldiers (even the one in our own family!), lethargy and denial can be deadly.  To persevere, we need situational awareness.

Finally, chapter 5 ends with the reality of grace in the fray of suffering (5:10-11).  Being humble and being alert are not states we dredge up by sheer will power, they are states of being we receive as gifts from a merciful Father. God works with purpose through all this hard life to strengthen and purify and transform us for our own good (v10), and for the glorious growing reality of God's putting the universe to rights (v11).  Or as we say in Serge, the world's good and God's glory.

Well, we're preaching to ourselves, so hopefully these thoughts from Scott encourage you too.  Throw off that red woolen blanket, hold up that little yellow plastic hand mirror, and accept that lovely gift bag.  Don't be surprised when trials come (I know I always am), but sink deeper into trust in the One who holds us all.

Direction: Death, a Path of Mercy and Truth

(3 babies squeezed onto one resuscitaire bed this morning, two were dead by this evening)

 (note neighborhood name on this file .. "Jesus Winner", still pushing the Gospel of Triumph)

One of my Lent devotions this week contained this paragraph: 

Therefore, let no confusion remain. Lent is not self-improvement. Lent is not self-denial for the sake of some moral gratification. At its most basic, Lent is about awaiting death. It is the uncomfortable and unwelcome reminder that we will grieve and we will die. For this reason, we can embrace the pain rather than avoid it. We can lead one another in lament over death’s temporary reign.

Jesus' disciples in the 40 days prior to his crucifixion certainly were not, for the most part, anticipating a march towards death.  They were still expecting the angel calvary, the miraculous zap to all enemies, the dramatic vindication.  Even as Jesus talked about losing your life to save it, taking up the cross, being a servant . . . they were arguing about seating arrangements in the palace.  That is me, too.  Lament and embracing inevitable pain all sound noble in a devotion.  But the actual determination to keep moving into areas of suffering, to keep facing death without fear, well, that's another story.  Just when I think we are faithful, it becomes excruciatingly hard.

For us, the walk towards death occurs every morning when we get up and go to another day at the hospital.  There is literal death, sometimes way too many.  Yesterday I lost four patients, today so far two.  Women arrive hourly with preterm twins, with a baby delivered on a bus still attached by her cord, with a convulsing lethargic infant, with an unconscious one-year-old deflated by diarrhea.  There's no screening here, no shielding, the raw effects of poverty and stress and physical labor and not-enough-to-eat just wash up on this doorstep over and over and over.  Yesterday as we tried to round and review the 38 babies we already had admitted in Newborn Unit, a nurse from radiology walked in with a rough wool blanket, inside was a 885 gram 26-week grey-blue limp newborn with no sign of life except a barely perceptible slow pulse.  The mom had been sent for an ultrasound because of abdominal pain, surprise, that was labor and this was a baby.  While I got the heart rate up and some response and breathing initiated the prognosis was very poor, and I had to decide to just leave this one on oxygen by pressure in an incubator while I ran to the operating theatre where Scott was delivering another 985 gram very small-for-age 32-week baby to save the life of the mother.  I literally walked in as the baby came out, and that one also needed a lot of resuscitation, and by the time I got him stabilized on his airway the other baby was dead.  And so it went.  We lost a 1-week old readmitted who had meningitis, and another baby with severe lung damage from a too-slow too-stressed birth with meconium, and a 29-week baby who delivered at home and was brought in infected and jaundiced.  And then 25-week twins, whose mother worked hard manual labor on farms.

(the very small-for-gestation baby delivered early to save his mom's life, so far still fighting)

But the walk towards death occurs in subtle ways, too. When we walk into that hospital, we never know what the staffing will be (38 babies, one senior nurse and one brand new one brought over from a dispensary to help on NBU, 50-some kids on the ward with two nurses as well).  The patient with asthma is just not improving . . only to find out no treatments had been given.  There is always something:  your colleague has to go to a meeting, pick up a document, appear in a court case.  The government is fighting with the university and interns are delayed in posting.  We're out of almost every antibiotic, or none of the labs are done because the machine is broken.  There are no gloves, or no IV cannulas.  Or bigger picture, there are protests in Nairobi, or roads closed, or political uncertainties.  There are wipe-you-out issues with people you care about.  There are rebel threats on borders, or potentially fatal illnesses. 

And death comes to certain dreams, or hopes.  Like not being with your med student son when he has surgery, or your soldier son on his pre-deployment vacation, or ever seeing your youngest son playing sports, or being able to reassure your graduating yet-to-be employed daughter that she can always live with you for a while (she can, but it's a long journey!).  Never having seen the rooms/homes/dorms of 3 of the 4 kids.  Moms who we never spend a birthday with.  Sisters who do almost all the attention for our mothers.  Planning that needs to happen but keeps getting pushed off to late evenings, funds that need raising.

I guess this week I've just been reflecting that the determination to keep going back into that fray, to keep plugging on in hard places, wears one down.  In my head I do believe that's what Jesus calls us to.  OK some people glorify God by being stars, speakers, well-known, moving in circles of the powerful, but that's not really our jam.  God asked us, we believe, to go to very dysfunctional places where injustice skews the outcomes, where every. single. day. something new doesn't work.  

So later in the week, in another devotional time, this verse popped out in Psalm 25 (v 10):  All the paths of the LORD are mercy and truth . . .David wrote that, David who suffered hunger, who suffered betrayal, who committed adultery and murder, who lost and regained his Kingdom, whose heart was broken by his son.  David wrote about humility, and then asked to be taught God's ways. 

So the Lent rubber meets the road, day after day, in our lives.  Can we accept that the quiet plod of faithfulness in the dirty corners of the world, even when it is frustrating and exhausting and unrewarding and costly, is a path of mercy and truth?  That being called to borders, to refugees, to cities, to isolated rural areas, to places where people are suspicious or hostile or demanding or incessantly persistently needy, is the very place where God pours out that mercy on us, and shows us the truth of who God is?

Let's lament the 6 babies who slipped away from life here in the last day and a half, and the uncounted others all around us.  Let's lament the broken jagged edges that centuries of sinful unjust choices have created.  Let's support each other as we call out the false Gospels of continuous triumph, always winning, comfort and ease as our birthrights.  Let's challenge each other to keep walking towards the margins.  Let's look for hints of mercy and truth, even as we walk straight into shadow, truly believing that this movement towards death paradoxically leads us to life.  

(another peri-natal collaboration between Scott and me, this one had a rough start but is peacefully anticipating discharge tomorrow)

(In honor of International Women's Day, with my two interns at lunch as I gave them a talk on TB.  These are two hard-working, unperturbed, non-complaining women and teach me to walk into challenge)